E-cigarettes may be a recruiting tool for some adolescents; exposure to depressed mom could drive substance abuse.

Action Points

Note that 29% of teenagers surveyed said they tried e-cigarettes, with 44% reporting use three or more times in the past month.

In another study, adolescents were more likely to engage in substance use and risky behavior if they were exposed to symptoms of maternal depression during their middle childhood years.

Several factors can affect the risk to kids for substance abuse and risky behavior. One study examined the issue by looking at the use of e-cigarettes and how it impacted the use of other substances, while separate research explored how early exposure to maternal depression led to substance use and risky behavior in adolescents.

E-Cigarettes: Teens Are Major Market

The danger e-cigarettes pose to teenagers appears to be increasing the longer e-cigarettes go unregulated.

According to a study in the January issue of Pediatrics, 29% of teenagers surveyed said they tried e-cigarettes, with 62% of those reporting use in the last month, and 44% reporting use three or more times in the past month.

In addition, 67% of respondents considered e-cigarettes to be "healthier" than regular cigarettes, reported Thomas A. Wills, PhD, professor at the University of Hawaii Cancer Center in Manoa, and colleagues.

Wills pointed out that teenagers may not realize e-cigarettes contain nicotine, which is an addictive substance. "One Surgeon General's report ... documented that, in several aspects, nicotine is more addictive than heroin," Wills said.

As e-cigarette use among the total population has doubled every year since 2009, teenagers have mirrored those trends. The National Youth Tobacco Survey reported e-cigarette ever-use among teenagers was up significantly from 4.7% in 2011 to 10.1% in 2012.

According to Wills' group, there are two possible hypotheses behind the appeal of e-cigarettes to teenagers. In one model, e-cigarettes act as a less dangerous alternative to cigarettes and were preferred by teenagers with "conservative and health oriented values." In another model, teenagers see e-cigarettes as similar to alcohol and marijuana or a way to "rebel against conventional values."

However, the data was unable to confirm either explanation. Although both notions are plausible, there is little empirical evidence to support or reject either theory at this time, the authors wrote.

They surveyed 1,941 students in three public and two private high schools in Oahu in 2013. The mean age of respondents was 14.6, with a 47% to 53% male-to-female demographic breakdown. Parental consent and adolescent assent were both required to participate in a 40-minute survey, and the response rate was 76%.

To determine the prevalence of e-cigarette use compared with cigarettes, alcohol, and marijuana, respondents were asked to determine frequency of use on a scale of 0 to 6 (0=never and 6=daily). E-cigarette ever-use (one to two times or more) was nearly double that of actual cigarettes (15%) and marijuana (18%), though it ranked second behind alcohol (47%).

When e-cigarette users were contrasted with users of both e-cigarettes and regular cigarettes, researchers reported dual users had a higher positive correlation (P>0.001) with social and behavioral risk factors.

Respondents who only used e-cigarettes did not score high on variables such as rebelliousness, sensation seeking, and peer smoker affiliations when compared with dual users, the authors wrote. But because they scored higher on these risk factors than their nonsmoking counterparts, the study determined e-cigarette users likely fall into an "intermediate risk group."

But when the study crossed e-cigarette users who also frequently used cigarettes, alcohol, or marijuana, there was a correlation (P>0.001) with 14 out of 15 psychosocial variables. Statements such as "I like to break the rules," "Smoking helps you feel more [self-confident]," and "Do any of your friends smoke cigarettes?" exhibited the greatest correlation with e-cigarette users who frequently used other substances.

"Our findings suggest that e-cigarettes may be operating to recruit lower-risk adolescents to smoking," Wills said. He also pointed out that both cigarette and e-cigarette use has increased among teenagers, which is difficult to reconcile with the contention that tobacco is being put out of business [by e-cigarettes], he said.

The most important limitation of the study may be its location. Hawaii has particularly aggressive advertising for e-cigarettes, and the authors pointed out that may lead to parents seeing e-cigarettes as a more desirable alternative and buying them for adolescents. Other limitations include lack of information about how long teenagers have been using e-cigarettes, and that the survey only collected data in one sitting.

"It would be desirable to follow a group of adolescents ... and obtain several assessments about e-cigarette use and cigarette use in order to determine how one type of use affects other types of use over time," Wills said.

Depressed Moms and Kids' Behavior

Adolescents are more likely to engage in substance use and risky behavior if they were exposed to symptoms of maternal depression during their middle childhood years, according to a study published online in Pediatrics.

The study found adolescents who had been exposed to "high symptoms" of maternal depression from ages 4 to 8, and "decreasing symptoms" as they got older were more likely to engage in "nonviolent delinquent behaviors" (P=0.03) as teenagers than adolescents exposed to a" lower level of maternal depressive symptoms." Such behaviors included "stealing, destruction of property, running away, and being out all night," reported Ian Colman, PhD, of the University of Ottowa, and colleagues.

Middle childhood is a period of increasing cognitive, social, and emotional development, which may be particularly relevant to the development of both internalizing and externalizing behavioral patterns, the authors wrote.

These adolescents were also more likely to use "common substances" such as cigarettes, alcohol, marijuana, and hallucinogenic drugs (P=0.005) and at an earlier age (P<0.001) than their study counterparts who had a low level of exposure to maternal depression during middle childhood.

This suggests a relationship between a child's development and a mother's state of mind, even before a child is old enough to make decisions about certain high-risk behaviors and activities.

"Maternal mental health is important throughout a child's life and not providing appropriate support and treatment for possible maternal mental illness may have consequences for their children," Colman said.

Mark A. Reinecke, PhD, professor, psychiatry and behavioral sciences at Northwestern University in Chicago, pointed out that until now, the majority of research and clinical attention about maternal depression has been focused on postpartum depression when children are infants or toddlers.

"I think what this study does is it encourages us to take a long view -- to think about maternal depression not just during early childhood and the perinatal period, but also the delayed effects of maternal depression," Reinecke said.

Researchers examined data from a Canadian cohort study, the National Longitudinal Survey of Children and Youth (NLSCY). The study analyzed a representative sample of 2,910 mother-youth pairs. Children were surveyed every 2 years, from 1994 to 1995 at the ages of 2 to 5, and ending in 2008 and 2009 until they reached age 16 or 17. Mothers of the children completed the questionnaires for them until they turned 10 or 11, when the children then answered the questions themselves.

Mothers were given a shortened form of the Center for Epidemiologic Studies Depression Scale (CES-D), which included a series of questions about their feelings (such as "I felt depressed" and "I felt hopeful about the future"). Respondents answered using four response categories ranging from "rarely to none of the time (<1 day)" to "most or all of the time (5-7 days)." Scores were calculated on a scale of 0 to 36, with mean scores of 3.98 to 4.81. The cutoff score for presence of depression was 12.

Although 10% to 17% of mothers at least exhibited the presence of depression, only 1.7% could have been diagnosed with clinical depression. But Reinecke suggested this distinction is important because it means having a mother who is merely feeling "sad or depressed or down" can still have an impact on a child's development. Screening for these kinds of feelings in women may be a practical, simple thing for a clinician to do, Reinecke said.

One limitation of the study was its time frame -- a questionnaire taken once every 2 years only gave an idea of the mother's state of mind around the period of the survey as opposed to over a longer time period. Both Colman and Reinecke also pointed out that while the study suggests middle childhood exposure to maternal depression may predict risky behavior in adolescents, there are likely other contributing factors.

"We would be really interested in finding out about the fathers and what their mental health might be like," Colman said. "I think there's a real gap in the literature about paternal depression and effects that may have on the child."

Reinecke observed that while the study may have statistical significance, it is unclear whether it has clinical significance. Several other variables, such as shared biology, a child's environment, learned experiences, and parental modeling also likely play a role in predicting substance abuse and risky behavior in teenagers, and would be additional theories a clinician should take into consideration.

"What are the biological, social, cognitive, and environmental factors of having a sad mother during 1 week or 2 weeks during your childhood that lead to these negative outcomes years later?" Reinecke said. "That's a conceptually important question."

The study by Wills' group was supported by the National Cancer Institute.

Wills and co-authors disclosed no relevant relationships with industry.

The study by Colman's group was supported by the SickKids Foundation, the Canadian Institutes of Health Research, and the Canada Research Chairs program for I.C.

Colman and co-authors disclosed no relevant relationships with industry.

Reviewed by Robert Jasmer, MD Associate Clinical Professor of Medicine, University of California, San Francisco and Dorothy Caputo, MA, BSN, RN, Nurse Planner

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